Utah s All Payer Claims Dataset: A vital resource for health reform

Transcription

1 TennCare Annual Meeting January19, 2011 Utah s All Payer Claims Dataset: A vital resource for health reform Keely Cofrin Allen, Ph.D. Director, Office of Health Care Statistics Utah Department of Health

2 Overview History Introduction to Utah Office of Health Care Statistics All Payer Claims Database History Data issues Analytic capabilities On going APCD Projects

3 BACKGROUND & HISTORY

4 Facts about Utah 2.75 million residents 1.85 commercial insured 300k each Medicaid, Medicare, Uninsured 70% live along the Wasatch Front Youngest average age & highest birth rate Among top 5 in state health rankings 5 health plans cover the majority of the population

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6 Health Data Committee 14 member board of stakeholders Payers Public health Providers (doctors & hospitals) Business Consumers Meets bi-monthly to set priorities Granted rule making authority

7 Office of Health Care Statistics 9 staff housed in Utah Dept. of Health Facility databases Inpatient, ED, and ambulatory surgery HEDIS & CAHPS All Payer Claims Database 10 major reports per year Ad-hoc analysis and projects 7

8 UTAH APCD: HISTORY

9 What is an APCD? Database of health plan modified outbound 837 claim data Enrollment Pharmacy Medical Organized into care episodes across time and care settings Includes diagnosis & payment information

10 State Progress Map

11 Utah Timeline 2006 Initial plan for Utah s APCD $1.2 million cost Failed in legislative vote 2007 Bill to plan an APCD No cost Creation of task force to write guideline document

12 APCD Data Plan (HB09) Report on statewide costs for episodes of care Made identified data necessary Standards for data submission Modified outbound 837 Use existing Utah Health Information Network Modified Utah Health Data Authority Act

13 Utah Timeline (con t) 2008 APCD building block Funded through health reform Meetings with health plan technical staff Policy and legal planning Administrative rule draft RFPs for data management and analysis vendors

14 APCD Vendors

15 Provides episode of care grouping software (CRGs) No cost to state entities On-going support and collaboration

16 RP Navigator software Web-based tool for APCD analysis Easily build tables by any variable in the database Build and save queries Efficient use of resources

17 X-12 translation services Data submission services Standards maintenance

18 Linking software Key to building episodes

19 Utah Timeline (con t) 2009 Rule in effect Testing files & submission processes LIVE: September 13 4 plans in production Preliminary analyses Reporting efforts

20 Utah Timeline (con t) 2010 Initial presentations to the Legislature First two APCD reports Outreach to data partners Beacon Community Grant Utah Health Insurance Exchange

21 health.utah.gov/utahatlas January 20,

22 Utah Timeline (con t) 2011 House Bill 128 Statewide quality measures Preparing for clinic-level reporting Medicaid data a big challenge Medicare data an even bigger challenge

23 APCD HEDIS measures HbA1c Screenings LDL-C Screenings for Diabetics Nephrophathy Screening Breast Cancer Screening 5+ Well- Child Visits APCD Average 59% 46% 30% 43% 50% State HEDIS Average 83% 73% 70% 60% 19%

24 APCD Awards 2011

25 Utah s APCD Covered Lives 19 plans engaged with the APCD: 8 in full production 2 enrollment and pharmacy only (Medicaid) 6 enrollment only 3 in testing phase (no data) 2.1 million covered lives representing 93% of the commercially insured market

26 Creating a Unique Person Primary Care Demographics Laboratory Radiology Hospital Surgery Pharmacy

27 APD Architecture

28 3 Levels of Data Security Physical Electronic Legal

29 Data Security Physical Data housed in locked & monitored server room at state Capitol Servers are limited access with no means of offloading data Server moved under armed security

30 Data Security Electronic Submission of encrypted and compressed files Secure FTP SSL with 256 bit encryption PHI protected with PGP algorithm s 2048 bit key

31 Data Security Legal Limited number of people with access to primary data warehouse Signed confidentiality agreements with termination and criminal charges HIPAA laws regarding PHI

32 Disease Percent of Total Health Care Costs Percent of Total Population Studied No. of People w/disease 1 Diabetes % 3.31 % 31,213 2 Hypertension 5.94 % 4.22 % 39,767 3 Asthma 4.62 % 2.50 % 23,606 4 Coronary Artery Disease 3.27 % 0.60 % 5,680 5 Breast Cancer 1.89 % 0.21 % 2,007 6 Depression 1.69 % 2.48 % 23,382 7 End Stage Renal Disease 1.69 % 0.13 % 1,237 8 Cerebrovascular Accident (Stroke) 1.51 % 0.15 % 1,377 9 Congestive Heart Failure 0.97 % 0.12 % 1, Chronic Obstructive Pulmonary Disease 0.72 % 0.12 % 1,116

33 Top Ten Therapeutic Class Classes Total Cost by Utilizing Cost Members Cost Per Utilizing Member Average Cost Per Script Percent Generic 1 ULCER DRUGS $22,198,987 71,613 $1,136 $79 76 % 2 ANTIDIABETICS $19,249,166 33,623 $1,445 $87 53 % 3 ANTIDEPRESSANTS $18,338,790 94,876 $531 $35 80 % 4 ANTIHYPERLIPIDEMICS $15,201,559 62,289 $658 $47 63 % 5 ANTIASTHMATIC AND BRONCHODILATOR AGENTS $14,187,136 52,501 $1,360 $81 8 % 6 ANALGESICS - OPIOID $11,508, ,968 $469 $26 96 % 7 ADHD / ANTI NARCOLEPSY / ANTI-OBESITY / ANOREXIANTS $11,245,893 29,251 $1,187 $84 38 % 8 ANTICONVULSANTS $11,111,165 34,016 $990 $63 86 % 9 DERMATOLOGICALS $10,904,253 99,052 $864 $57 69 % 10 ANTIPSYCHOTICS / ANTIMANIC AGENTS $9,880,361 10,620 $3,018 $ %

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35 3M Clinical Risk Groups A clinical model that assigns individuals to a single risk group CRG classification is based on clinical history and demographics Projects the amount of healthcare resources the individual will consume in the future Nine groups each with its own severity levels

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37 Each person is put into one of the blue boxes

38 Uses of CRGs Classification into CRGs can be used to examine the data categorically CRGs provide a framework to understand how healthcare resources are allocated Can be used to risk adjust within an exchange

39 Where are Utah Healthcare Dollars Going? Catastrophic Conditions Metastatic Malignancies Three or More Significant Chronic Diseases Chronic Disease Among 21.1% Utahns Represent 53.3% of the Healthcare Costs Two Significant Chronic Diseases Single Significant Chronic Disease Multiple Minor Chronic Diseases Single Minor Chronic Disease Significant Acute Disease Percent of Healthcare Dollars Spent in Category Percent of Utah Residents Falling in Category Routine & Preventive Care/Non-Users 0% 10% 20% 30% 40% 50% 60% 70%

40 Outliers? Diabetes EOCs, BOI, and costs * Cost for just the diabetes portion of care medical and pharmaceutical (does not include co-payments) Number of Episodes Evaluated Burdon Of Illness EOC Cost (Medical)* EOC Cost (Rx) *

41 Darker color = Higher

42 Burden of Illness (BOI) A single number assigned to each person Represents the disease burden as a continuous variable from 0 to BOI is adjusted by age and sex Average BOI in the Utah population: 1.01 Measure has been verified by analyses by the Society of Actuaries

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44 Diabetes: BOI by CRG & Severity CRG 5 CRG Severity Level

45 Diabetes: Episode Cost by CRG & Severity $17,000 $15,000 $13,000 $11,000 $9,000 $7,000 CRG 5 CRG 6 $5,000 $3,000 $1, Severity Level

46 Copyright APCD Council, NAHDO, UNH APCD Meeting May 6, Copyright APCD Council, NAHDO, UNH 46

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48 Thank you! Keely Cofrin Allen